APH Summary

APH Definition

  • Bleeding from genital tract
  • ≥24 weeks gestation
  • Before birth of baby
  • Classifications: Minor, Major, Massive

Placenta Praevia

  • Painless bleeding
  • Soft non-tender uterus
  • No fetal distress
  • Shock proportional to visible loss

Placental Abruption

  • Painful bleeding
  • Tender 'woody' uterus
  • Fetal distress common
  • Shock disproportionate to loss

Initial Assessment

  • Maternal stabilization first
  • Assess bleeding severity
  • Check fetal wellbeing
  • No vaginal exam if praevia suspected

Key Investigations

  • FBC, coagulation screen
  • Crossmatch 4 units
  • Kleihauer test (RhD-negative)
  • Ultrasound for placental location
  • CTG for fetal assessment

Emergency Management

  • ABCD assessment
  • Two large-bore IV access
  • Left lateral position
  • Crossmatch and transfuse
  • Anti-D for RhD-negative

Critical Points

  • Mother is priority
  • No VE if praevia suspected
  • Abruption is clinical diagnosis
  • Massive hemorrhage protocol

Antepartum Haemorrhage (APH)

Bleeding from genital tract occurring from 24+0 weeks of pregnancy prior to birth

Definition and Classification

Antepartum haemorrhage (APH) is defined as bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.

Severity Classification

Minor Haemorrhage

  • Blood loss less than 50 ml
  • Bleeding has settled

Major Haemorrhage

  • Blood loss of 50–1000 ml
  • No signs of clinical shock

Massive Haemorrhage

  • Blood loss greater than 1000 ml
  • AND/OR signs of clinical shock

Major Causes Comparison

The most important causes of APH are placenta praevia and placental abruption, although these are not the most common.

Feature Placenta Praevia Placental Abruption
Pain Painless Painful
Uterus Soft non-tender Tender 'woody' uterus
Fetal Status No fetal distress Fetal distress common
Clinical Shock Proportional to visible loss Disproportionate to visible loss

Placenta Praevia

Definition

Placenta praevia occurs when the placenta is inserted wholly or in part into the lower segment of the uterus.

  • Major: Placenta covering internal os
  • Minor: Leading edge in lower segment but not covering os

Clinical Presentation

  • Incidental finding on routine ultrasound
  • Painless bleeding usually after 28 weeks
  • Sudden and profuse but short-lasting
  • Rarely life-threatening
  • High presenting part or abnormal fetal lie

Risk Factors

Obstetric History

  • Previous placenta praevia
  • Previous caesarean sections
  • Previous termination of pregnancy
  • Multiparity

Maternal Factors

  • Advanced maternal age (>40 years)
  • Multiple pregnancy
  • Smoking
  • Assisted conception

Uterine Factors

  • Deficient endometrium
  • Uterine scar
  • Endometritis
  • Manual removal of placenta
  • Curettage
  • Submucous fibroid

Important: Avoid vaginal and rectal examinations in women with placenta praevia, and advise these women to avoid penetrative sexual intercourse.

Placental Abruption

Definition

Placental abruption is the premature separation of a normally placed placenta before delivery of the fetus with blood collecting between the placenta and the uterus.

  • Concealed (20%): Haemorrhage confined within uterine cavity
  • Revealed (80%): Blood drains through cervix

Clinical Presentation

  • Vaginal bleeding
  • Continuous abdominal pain
  • Uterine contractions
  • Shock or fetal distress
  • Tense, tender uterus with 'woody' feel
  • Haemodynamic compromise disproportionate to visible loss

Risk Factors

Obstetric Factors

  • Previous placental abruption
  • Pre-eclampsia
  • Fetal growth restriction
  • Non-vertex presentations
  • Polyhydramnios

Maternal Factors

  • Advanced maternal age
  • Multiparity
  • Low BMI
  • Pregnancy following ART
  • Intrauterine infection

External Factors

  • Premature rupture of membranes
  • Abdominal trauma
  • Smoking
  • Drug misuse (cocaine, amphetamines)

Note: Ultrasound is not reliable at identifying abruption. This is primarily a clinical diagnosis.

Clinical Assessment

The mother is the priority in these situations and should be stabilised prior to establishing the fetal condition.

Triage Process

Initial Assessment
  1. History taking for coexisting symptoms (especially pain)
  2. Assessment of extent of vaginal bleeding
  3. Cardiovascular condition of mother
  4. Assessment of fetal wellbeing

Examination

Abdominal Examination

  • Assess for tenderness or acute abdomen signs
  • 'Woody' uterus indicates significant abruption
  • Check for uterine contractions
  • Soft, non-tender uterus suggests lower tract cause or praevia

Speculum Examination

  • Identify cervical dilatation
  • Visualise lower genital tract cause
  • Safe if placenta praevia excluded

Digital Vaginal Examination

  • CONTRAINDICATED if placenta praevia possible
  • Only after ultrasound excludes praevia
  • Can assess cervical dilatation if APH with pain

Investigations

Blood Tests

Major/Massive Haemorrhage

  • FBC and coagulation screen
  • Crossmatch 4 units of blood
  • Urea, electrolytes, LFTs
  • Initial Hb may not reflect blood loss
  • Low platelets may indicate consumptive process

Minor Haemorrhage

  • FBC and group and save
  • Coagulation screen only if platelets abnormal

RhD-negative Women

  • Kleihauer test to quantify FMH
  • Determine anti-D immunoglobulin dose

Imaging and Fetal Assessment

Ultrasound

  • Confirm/exclude placenta praevia
  • Well-established for placental location
  • Not reliable for abruption diagnosis

Fetal Assessment

  • Cardiotocograph (CTG) once mother stable
  • Aids delivery mode decision
  • Ultrasound for fetal heart if external auscultation fails

Management

Disposition Decisions

Home Discharge

  • Spotting only
  • No ongoing bleeding
  • Placenta praevia excluded
  • Reassuring initial assessment

Hospital Admission

  • APH heavier than spotting
  • Ongoing bleeding
  • Remain until bleeding stops

Immediate Delivery

  • Maternal and/or fetal compromise
  • Caesarean section if fetus compromised
  • Concurrent maternal resuscitation

Massive APH Protocol

Emergency Management Steps
  1. ABCD assessment
  2. High-flow oxygen (10-15L/min via facemask)
  3. Two 14-gauge IV lines
  4. Bloods: FBC, coagulation, U&E, crossmatch 4 units
  5. Left lateral tilt position
  6. Keep warm
  7. Transfuse blood ASAP (use O RhD-negative if needed)
  8. Fluid resuscitation: Up to 3.5L warmed crystalloid/colloid
  9. Coagulation support: 4 units FFP + 10 units cryoprecipitate
  10. Assess fetus and decide on delivery

Therapeutic Goals

Parameter Target
Haemoglobin > 8 g/dl
Platelet count > 75 × 10⁹/l
Prothrombin time < 1.5 × mean control
APTT < 1.5 × mean control
Fibrinogen > 1.0 g/l

Anti-D Immunoglobulin: Give to all non-sensitised RhD-negative women after any APH presentation, independent of routine antenatal prophylactic anti-D.

Complications

Maternal Complications

  • Anaemia
  • Infection
  • Maternal shock
  • Renal tubular necrosis
  • Consumptive coagulopathy (DIC)
  • Postpartum haemorrhage
  • Prolonged hospital stay
  • Psychological sequelae
  • Blood transfusion complications

Fetal Complications

  • Fetal hypoxia
  • Small for gestational age
  • Fetal growth restriction
  • Prematurity (iatrogenic and spontaneous)
  • Fetal death